Safety and efficacy of target-controlled infusion versus intermittent bolus administration of propofol for sedation in colonoscopy: a randomized controlled trial

Abstract Background: Our objective was to compare the safety and efficacy of Target-Controlled Infusion (TCI) versus intermittent bolus of propofol for colonoscopy sedation. Methods: We conducted a randomized (1:1), single-blind, parallel-group superiority trial with fifty ASA I or II patients, both sexes, aged 18 to 65 years, Body Mass Index ≤ 30 kg.mr-2, undergoing colonoscopy, allocated to receive propofol by TCI (effect-site, 2 μg.mL-1 plus 0.5 μg.mL-1 until unconsciousness and as necessary for agitation) or intermittent bolus (1 mg.kg-1 plus 0.5 mg.kg-1 every 5 minutes or as above). The primary safety outcome was the need for airway maneuvers and the primary efficacy outcome was the need for interventions to adjust the level of sedation. Secondary outcomes included incidence of agitation, propofol dose, and time to recovery. Results: The median (IQR) number of airway maneuvers and interventions needed to adjust sedation was 0 (0-0) vs. 0 (0-0) (p = 0.239) and 1 (0-1) vs. 3 (1-4) (p < 0.001) in the TCI and control groups, respectively. Agitation was more common in the intermittent bolus group - 2 (0-2) vs. 1 (0-1), p < 0.001. The mean ± SD time to recovery was 4.9 ± 1.4 minutes in the TCI group vs. 2.3 ± 1.6 minutes in the control group (p < 0.001). The total propofol dose was higher in the TCI group (234 ± 46 μg.kg-1.min-1 vs. 195 ± 44 μg.kg-1.min-1 (p = 0.040)). Conclusions: During colonoscopy, TCI is as safe as intermittent bolus of propofol while reducing the incidence of agitation and the need for dose adjustments. However, intermittent bolus administration was associated with lower total propofol dose and earlier recovery.

P-l Assoun and the irony inherent in the unconscious / P-l assoun e a ironia inerente ao inconsciente

RESUMO: Figura polissêmica e polimorfa, de expressiva abrangência, a ironia é objeto de sucessivas análises de múltiplas áreas de estudos, o que contrasta com a quantidade de estudos psicanalíticos dedicados a ela. Este trabalho busca circunscrever e discutir a ideia de uma ironia inerente ao inconsciente proposta por Assoun e mostrar que comentários temáticos e críticos de textos elementares podem fornecer subsídios para a abordagem da ironia pela psicanálise, mesmo se comportarem um viés retrospectivo e comparativo.

ABSTRACT: A polysemic and polymorphic figure, of expressive scope, irony is the subject of successive analyses of multiple study areas, which contrasts with the amount of psychoanalytical studies dedicated to it. This work seeks to circumscribe and discuss the idea of an irony inherent to the unconscious proposed by Assoun and to show that thematic and critical comments of elementary texts can provide subsidies to the approach of irony by psychoanalysis, even if they have a retrospective and comparative bias.

Hernia diafragmática traumática derecha en paciente geriátrico. Reporte de un caso infrecuente / Traumatic right diaphragmatic hernia in an elderly patient. A rare case report

Introducción: La hernia diafragmática surge como resultado del movimiento de los órganos abdominales hacia el tórax a través de un defecto del diafragma resultante de varios tipos de lesiones, que a menudo representan un desafío diagnóstico y terapéutico. La hernia diafragmática traumática es una enfermedad infrecuente. El trauma diafragmático rara vez es aislado, la mayoría de las veces se acompaña de otras lesiones toracoabdominales, cerebrales o musculoesqueléticas, siendo estas comorbilidades más graves responsables del mal pronóstico y aumento de la mortalidad. Caso clínico: Anciana de 90 años de edad, hipertensa, quien inicia cuadro clínico 48 horas previas a su ingreso, cuando posterior a caída del plano de bipedestación presenta disminución del estado de consciencia, náuseas, vómitos y disnea en reposo. Rx de tórax evidencia asas intestinales en hemitórax derecho. Se realizó laparotomía exploradora. Conclusión: Las hernias diafragmáticas traumáticas son infrecuentes, con incidencia <3%, sintomatología inespecífica y relacionadas generalmente con lesiones asociadas al trauma. Siempre se debe sospechar de una HD ante un paciente con antecedente de trauma cerrado de alto impacto o penetrante, en función de la cinética y mecanismo de lesión. El diagnóstico supone un reto para el cirujano, debiendo apoyarse en una firme sospecha y estudios radiológicos. Su tratamiento es quirúrgico, debiendo ser individualizado, con abordajes torácicos o abdominales en función del caso. La técnica a emplear dependerá de las características del defecto, de la fase del diagnóstico y la experiencia del equipo quirúrgico(AU)

Introduction: Diaphragmatic hernia arises as a result of the movement of the abdominal organs towards the thorax through a defect in the diaphragm resulting from various types of injuries, which often represent a diagnostic and therapeutic challenge. Traumatic diaphragmatic hernia is a rare disease. Diaphragmatic trauma is rarely isolated, most of the time it is accompanied by other thoracoabdominal, brain or musculoskeletal injuries, these more serious comorbidities being responsible for the poor prognosis and increased mortality. Clinical case: A 90-year-old woman with hypertension , who began a clinical picture 48 hours prior to admission, when after falling from the standing plane he presented a decreased state of consciousness, nausea, vomiting, and dyspnea at rest. Chest x-ray shows intestinal loops in the right hemithorax. Exploratory laparotomy was performed. Conclusion: Traumatic diaphragmatic hernias are rare, with an incidence of <3%, non-specific symptoms, and generally related to injuries associated with trauma. HD should always be suspected in a patient with a history of high-impact or penetrating blunt trauma, depending on the kinetics and mechanism of injury. Diagnosis is a challenge for the surgeon, and must be based on a firm suspicion and radiological studies. Its treatment is surgical, and must be individualized, with thoracic or abdominal approaches depending on the case. The technique to be used will depend on the characteristics of the defect, the diagnostic phase and the experience of the surgical team(AU)

Contribuições da clínica de linguagem para uma discussão psicanalítica sobre a contradição nos dizeres / Contributions of the language clinic for a psychoanalytic discussion on contradiction in speech

RESUMO: A partir da constatação de contradições cotidianas e de sua recepção na lógica clássica, onde não são admitidas, este trabalho teórico interroga, junto a outros campos, fenômenos linguageiros considerados indesejáveis e, consequentemente, descartáveis em descrições e análises. A discussão reconhece na Lógica paraconsistente avanços importantes para a abordagem das contradições em sistemas lógicos. Na Clínica de Linguagem, tropeços e embaraços são tratados como dados de subjetividade relevantes para elaborações teórico-clínicas; ali encontramos contribuições para discutir a contradição na Psicanálise. Resta dizer que o interesse pela questão decorre da afirmação de Freud de que a vida psíquica é composta de contradições.

ABSTRACT: Based on the observation of everyday contradictions and their reception in classical logic, where they are not admitted, this theoretical work interrogates, together with other fields, linguistic phenomena considered undesirable and disposable in descriptions and analyses. The discussion recognizes in Paraconsistent Logic important advances for the approach of contradictions in logical systems. At the Language Clinic, stumbling blocks and embarrassments are treated as relevant subjectivity data for theoretical-clinical elaborations; there we find contributions to discuss the contradiction in Psychoanalysis. It remains to be said that the interest in the question stems from Freud's assertion that psychic life is made up of contradictions.

L'inconscient est politique / O inconsciente é a política: sobre as distopias na sociedade brasileira contemporânea / The unconscious is politics: about dystopias in contemporary brazilian society

RESUMO. A intenção deste ensaio é circunscrever na tradição social brasileira recente a problemática do populismo de extrema direita, em uma retomada e repetição do que se passou nos tempos nefastos da ditadura militar. Para isso, vamos destacar a dívida estabelecida pela sociedade brasileira para com os mortos, na medida em que os crimes realizados pela ditadura não foram julgados. Além disso, tal dívida remete a outras dívidas existentes na sociedade brasileira, referentes à tradição escravocrata, assim como as relações patriarcais no registro do gênero.

RESUME: L'intention de cet essai est de circonscrire dans la récente tradition sociale brésilienne la problématique du populisme d'extrême droite, dans une reprise et une répétition de ce qui s'est passé dans les temps néfastes de la dictature militaire. Pour cela, nous soulignerons la dette établie par la société brésilienne envers les morts, dans la mesure où les crimes perpétrés par la dictature n'ont pas été jugés. En outre, cette dette fait référence à d'autres dettes existant dans la société brésilienne, se référant à la tradition esclavagiste, ainsi qu'aux relations patriarcales dans le registre des sexes.

ABSTRACT. This essay intends to circumscribe in the recent Brazilian social tradition the problem of far right-wing populism, in a resumption and repetition of what happened in the nefarious times of the military dictatorship. For this, we analyzed the debt established by Brazilian society towards the dead, insofar as the crimes committed by the dictatorship were not judged. In addition, this debt refers to other existing debts in Brazilian society, referring to the slavery tradition, as well as gender related patriarchal relations.

Reflexo e sombra: o duplo e o narcisismo em hoffmann e chamisso / Reflection and shadow: the double and the narcissism in hoffmann and chamisso / Reflejo y penumbra: el doble y el narcisismo en hoffman y chamisso

Esta é uma pesquisa qualitativa, em formato de ensaio, que realiza o estudo comparado de duas obras literárias, de A. Von Chamisso e E. T. A. Hoffmann, e de uma anotação do diário deste último para problematizar a repercussão de algumas formas de desestabilizações do Eu na dinâmica psíquica da neurose. O foco dos textos referidos está no fenômeno do duplo na sua forma negativizada, isto é, como o desaparecimento da imagem exterior que dá suporte ao Eu. As ausências da sombra e do reflexo são entendidas como representações metafóricas de uma alteração do Eu que engendra repercussões importantes na homeostase psíquica, sobretudo nas relações sociais de troca. Explora-se daí a menção no diário de Hoffmann de instrumentos ópticos para interrogar o uso desses aparelhos como modelos metapsicológicos na psicanálise. Salienta-se, ainda, a participação de processos de natureza estética na dinâmica psíquica do infamiliar, tomando como referência a ligação entre o conto de Hoffmann e o relato de Stendhal sobre a sua estadia em Florença.(AU)

This is a qualitative research, in essay format, which performs the comparative study of two literary works, by A. Von Chamisso and E. T. A. Hoffmann, and an annotation in the latter's diary to problematize the repercussion of some forms of destabilization of the Ego's in the psychic dynamics of neurosis. The focus of the referred texts is on the phenomenon of the double in its negative form, that is, as the disappearance of the outer image that supports the Ego. The absences of the shadow and the reflection are understood as metaphorical representations of an alteration of the Ego that generates important repercussions on psychic homeostasis, above all in social relationships of exchange. Thus, we analyze the mention of optical instruments in Hoffmann's diary to question the use of these devices as metapsychological models in psychoanalysis. Note, also, the participation of processes of aesthetic nature in the psychic dynamics of the uncanny, taking as reference the connection between Hoffmann's short story and Stendhal's account of his stay in Florence.(AU)

Este ensayo cualitativo realiza un estudio comparativo de dos obras literarias de A. Von Chamisso y de E. T. A. Hoffmann, junto con una anotación en el diario de este último para problematizar la repercusión de algunas formas de desestabilizaciones de la función del Yo en la dinámica psíquica de la neurosis. Los textos se centran en el fenómeno del doble en su forma negativa, como la desaparición de la imagen exterior que sostiene el Yo. Se entienden las ausencias de la penumbra y el reflejo como una representación metafórica de una alteración de la función del Yo que genera importantes repercusiones en la regulación psíquica, sobre todo en las relaciones de intercambio social. Se analiza la presencia en el diario de Hoffmann de instrumentos ópticos para discutir el uso de estos dispositivos como modelos metapsicológicos en psicoanálisis. Se destaca la reverberación de procesos de naturaleza estética en la dinámica psíquica de lo ominoso, tomando como referencia la conexión entre el cuento de Hoffmann y el relato de Stendhal sobre su estancia en Florencia.(AU)

Troubles de la conscience au service de réanimation polyvalente du Centre Hospitalier Universitaire Analakininina, Toamasina, Madagascar / Impaired consciousness in the intensive care unit at Analankininina Teaching Hospital of Toamasina, Madagascar

La survenue d'un coma ou de troubles de la conscience en réanimation est très fréquemment observée et leur présence est associée à un pronostic sévère. Nos objectifs étaient de décrire le profil épidémio-clinique des patients admis pour coma et trouble de la conscience ainsi que les principales étiologies de ces manifestations cliniques. Méthodes : Il s'agissait d'une étude prospective, descriptive, longitudinale de Juin à Novembre 2019. Le cadre de notre étude était le service de réanimation polyvalente du centre hospitalier universitaire (CHU) Analakininina Toamasina. Résultats : Nous avions recensé 77 patients dont 37 femmes et 40 hommes (sex ratio de 1,081). La moyenne d'âge était de 39 +/-17 ans. La majorité des patients soit 67% présentait un trouble de la conscience, le reste (31%) était comateux. La principale étiologie des troubles rencontrés était l'AVC (53%) dont 61% était hémorragiques, 17% ischémiques, et 22% non étiquetés. Plus de la moitié des patients avaient évolué vers le décès (61%). Conclusion : Pour l'amélioration du pronostic des patients, il serait nécessaire de connaitre les étiologies fréquentes afin d'adapter la prise en charge

What is there in chinese writing that can guide us about the instance of the letter in the unconscious? / O que há na escrita chinesa que possa nos orientar acerca da instância da letra no inconsciente?

RESUMO: Este artigo versa sobre as relações entre o sistema de escrita chinês e a instância da letra no inconsciente. Para isso, revisamos teoricamente uma rede de conceitos imbricados que suportam essa questão na Linguística, com Saussure e Peirce, e na Psicanálise lacaniana: escrita, letra, signo e significante, lidos a partir da experiência de aprendizado do Mandarim e de recortes clínicos de situação de análise. Tal percurso nos apontou que, ao escutar um sujeito em análise, além da escuta de seus significantes, devemos nos atentar à dimensão do que é letra, inclusive na sua dimensão visual, para então, quiçá, transpor algo disso para o simbólico.

Abstract: This article discusses the relation between the Chinese writing system and the instance of the letter in the unconscious. We review theoretically a network of interwoven concepts that support this issue in Saussure and Lacan: writing, signifier and letter rethought from the learning experience of Mandarin and from clinical clippings of analysis situation. This way showed us that while listening to a subject in analysis, in addition to listening to its significant, we must be aware of the dimension of what the letter is, including its visual dimension, so then, perhaps, transpose something from it to the symbolic.

Contributions of René Kaës to the epistemology of psychoanalysis / Contribuições de rené kaës para a epistemologia da psicanálise

RESUMO: O objetivo deste artigo é discutir os efeitos das alianças inconscientes na restrição à extensão da psicanálise no que se refere à construção do conhecimento psicanalítico sobre os grupos. Cinquenta e cinco textos publicados na Revista Brasileira de Psicanálise RBP, entre 1967 e 1976, foram analisados a partir do referencial teórico-metodológico proposto por René Kaës. Numa breve reconstrução histórica, operou-se com o conceito de alianças inconscientes com o propósito de investigar as bases narcísicas presentes desde as origens da psicanálise; que restringiram a capacidade de pensar o grupo no campo da psicanálise. Benefícios narcísicos foram extraídos destas resistências que ainda hoje dificultam a extensão da psicanálise no que diz respeito à inclusão do grupo como objeto teórico.

Abstract: Contributions of René Kaës to the epistemology of psychoanalysis. The objective of this article is to discuss the effects of the unconscious alliances on extension of psychoanalysis. 55 texts published in the Revista Brasileira de Psicanálise between 1967 and 1976 were analyzed under the theoretical framework of René Kaës. A brief historical reconstruction with the concept of unconscious alliances in order to investigate the narcissistic bases present since the origins of psychoanalysis; that restricted the capacity to think in the group in the field of psychoanalysis. Narcissistic benefits were extracted of this resistance, that still today difficult the extension of the psychoanalysis for the inclusion of the group as a theoretical object.

Embolismo cerebral durante vuelo comercial: reporte de caso / Cerebral embolism during commercial flight: case report

RESUMEN Presentamos el caso de un varón de 25 años con antecedentes de consumo de marihuana y tabaco, que durante viaje en vuelo comercial a Cusco presentó disnea, pérdida de conciencia y estado epiléptico. Arribó a esta ciudad presentando hipotensión arterial, murmullo pulmonar abolido, sin recuperación de conciencia. La tomografía de tórax reveló bullas pulmonares y la tomografía mostró neumoencéfalo, diagnosticándose embolia gaseosa cerebral. La hipoxemia asociada a convulsiones y pérdida de conciencia en una persona joven durante el vuelo no es un evento común. La pérdida de la presión en la cabina durante el ascenso parece ser el evento desencadenante en pacientes con enfermedad pulmonar.

ABSTRACT We present the case of a 25-year old man with a history of marijuana and tobacco consumption who, during a commercial flight to Cusco, presented dyspnea, loss of consciousness, and epileptic condition. He arrived in this city presenting arterial hypotension, abolished pulmonary murmur, with no recovery of consciousness. The thorax tomography revealed lung bullae and the tomography showed pneumocephalus. He was diagnosed with cerebral gas embolism. Hypoxemia associated with seizures and loss of consciousness in a young person during a flight is not a common event. Loss of cabin pressure during climb appears to be the triggering event in patients with lung disease.

Intermittent loss of consciousness during cesarean section under spinal anesthesia: a case report / Perda intermitente de consciência durante cesariana sob raquianestesia: relato de caso

Abstract Loss of consciousness during spinal anesthesia is a rare but scary complication. This complication is generally related to severe hypotension and bradycardia, but in this case, the loss of consciousness occurred in a hemodynamically stable parturient patient. We present a 31 years-old patient who underwent an emergency cesarean section. She lost consciousness and had apnea that started 10 minutes after successful spinal anesthesia and repeated three times for a total of 25 minutes, despite the stable hemodynamics of the patient. The case was considered a subdural block, and the patient was provided with respiratory support. The subdural block is expected to start slowly (approximately 15-20 minutes), but in this case, after about 10 minutes of receiving anesthesia, the patient suddenly had a loss of consciousness. After the recovery of consciousness and return of spontaneous respiration, the level of a sensory block of the patient, who was cooperative and oriented, was T4. There were motor blocks in both lower extremities. Four hours after intrathecal injection, both the sensory and motor blocks ended, and she was discharged two days later with no complications. Hence, patients who receive spinal anesthesia should be closely observed for any such undesirable complications.

Resumo A perda de consciência durante a raquianestesia é uma complicação rara, mas assustadora. Essa complicação geralmente está relacionada à grave hipotensão e bradicardia, mas, neste caso, a perda de consciência ocorreu em uma paciente parturiente hemodinamicamente estável. Apresentamos o caso de uma paciente de 31 anos, submetida a uma cesariana de emergência. A paciente perdeu a consciência e apresentou apneia que teve início 10 minutos após a raquianestesia bem-sucedida e repetiu o episódio três vezes por 25 minutos, a despeito de sua hemodinâmica estável. O caso foi considerado como um bloqueio subdural e a paciente recebeu suporte respiratório. Espera-se que o bloqueio subdural inicie lentamente (aproximadamente 15-20 minutos), mas, neste caso, cerca de 10 minutos após a anestesia, a paciente repentinamente perdeu a consciência. Após a recuperação da consciência e o retorno da respiração espontânea, a paciente que estava orientada e cooperativa apresentou nível de bloqueio sensorial em T4. Havia bloqueio motor em ambas as extremidades inferiores. O bloqueio sensório-motor terminou quatro horas após a injeção intratecal e a paciente recebeu alta hospitalar dois dias depois, sem complicações. Considerando o exposto, os pacientes que recebem raquianestesia devem ser atentamente observados para quaisquer complicações indesejáveis.

O vivo incomensurável: entre ciência e inconsciente / The incommendable living: between science and the unconscious

Pensar o laço entre neurociências e psicanálise obriga a pensar no incomensurável: pensar a partir do "nada em comum", para além de toda tradução, superposição, analogia redutora ou relação causa-efeito simplista. Senão permaneceremos nos pulos da pulga. Se pegarmos uma pulga, batermos uma palma: ela salta. Se lhe tirarmos uma pata, depois duas, depois três, ela salta cada vez menos longe. Se lhe tirarmos todas as patas, ela não salta de modo algum tal como quando batemos palma. Conclusão: a audição está nas patas! Há, com efeito, sempre o mesmo risco na interpretação das funções do cérebro: de ser tomado em uma relação estrutura-função simplista, linear, contínua, sem resto culminando em um falso raciocínio malgrado suas roupagens de evidência.

¿El siglo de las luces? / The lights century?

El siglo de las luces es una reflexión sobre el excesivo racionalismo de la medicina actual frente a los problemas del inconsciente dejando de lado el análisis del inconsciente del sujeto y la posibilidad del sujeto de mirarse así mismo.

This paper is a reflection about the excessive rationalism of current medici-ne against the unconscious problems leaving aside the analysis of the un-conscious of the person and the possibility of the person to look at himself.

O inconsciente e a lógica a partir de freud e lacan / The unconscious and the logic from freud and lacan

RESUMO: Nós propomos, neste artigo, uma interpretação da seguinte passagem do Abriss der Psychoanalyse de Freud: "As regras decisivas da lógica não têm validade no inconsciente, pode-se dizer que ele é o reino do ilógico". Para tanto, procederemos em quatro etapas: 1) Delimitar o conceito de lógica a partir do Organon de Aristóteles. 2) Identificar quais são as regras decisivas da lógica e seu conteúdo. 3) Examinar em que sentido tais regras não possuem validade no inconsciente. 4) Problematizar a tese freudiana de que o inconsciente seria o reino do ilógico. A ideia de que esta tese freudiana é problemática surge de uma tese que Lacan apresenta no seminário XIV sobre a lógica da fantasia, a saber, que o inconsciente "está instalado no campo da lógica e que ele articula proposições". Esta tese lacaniana nos permitirá chegar à conclusão de que o inconsciente não é totalmente o reino do ilógico.

Abstract: We propose, in this paper, an interpretation of this passage in Freud's Abriss der Psychoanalyse: "The decisive rules of logic don't apply in the unconscious, we could call it the Empire of the illogical". To do this, we are going to follow these steps: 1) Define the concept of logic through Aristotle's Organon. 2) Identify the decisive rules of logic and their contents. 3) Examine in what sense these rules don't apply in the unconscious. 4) Call into question Freud's thesis that unconscious would be the Empire of the illogical. The idea that this Freudian thesis is problematic comes from a thesis which Lacan presents in the seminar XIV on the logic of phantasy, namely that the unconscious "is installed in the field of logic and that it articulates propositions". This thesis will allow us to conclude that the unconscious is not completely the Empire of the illogical.

Costo-efectividad de la reanimación cardiopulmonar con el uso del desfibrilador externo automático, comparado con reanimación cardiopulmonar básica, para personas con pérdida de conciencia en espacios de afluencia masiva de público / Cost-effectiveness of cardiopulmonary resuscitation using an automated external defibrillator compared with a basic defibrillator in unconscious patients in crowded public spaces in Colombia

Resumen Objetivo: Estimar la razón de costo-efectividad de la reanimación cardiopulmonar con el uso del desfibrilador externo automático (DEA), comparado con la reanimación cardiopulmonar básica, para la reanimación de personas con pérdida de conciencia en espacios de afluencia masiva de público en Colombia. Métodos: Para estimar los costos y desenlaces de las dos alternativas de comparación, se diseñó un árbol de decisiones en el cual se reflejan los principales desenlaces posterior a la pérdida de conciencia y la reanimación con cualquiera de las dos alternativas. Se asumió la perspectiva del sistema de salud colombiano en un horizonte temporal comprendido entre el momento de la pérdida de conciencia de la persona hasta el ingreso al hospital. Las probabilidades de los eventos se obtuvieron de un meta-análisis de ensayos clínicos y la información de costos de fuentes oficiales y consulta directa a proveedores de DEA en Colombia. Los costos fueron expresados en pesos colombianos de 2016 y la efectividad en muertes evitadas. Se realizaron análisis de sensibilidad determinísticos y probabilísticos para estimar el impacto de la incertidumbre sobre las conclusiones. Resultados: La razón de costo-efectividad de la reanimación cardiopulmonar con DEA fue de $3.267.777 por muerte evitada. La probabilidad de que esta intervención sea costo-efectiva es superior al 90% para un umbral de costo-efectividad superior a 10 millones de pesos. Conclusión: Un programa de reanimación cardiopulmonar con desfibrilación temprana mediante el uso de DEA, en espacios de afluencia masiva de público, es una alternativa costo-efectiva para el sistema de salud colombiano.

Abstract Objective: To estimate the cost-effectiveness of cardiopulmonary resuscitation using an automated external defibrillator (AED) compared with basic cardiopulmonary resuscitation, for the resuscitation of unconscious patients in crowded public spaces in Colombia. Methods: A decision tree was designed in order to estimate the costs and outcomes of the two alternatives. This included the main outcomes after the loss of consciousness and resuscitation by any of the two alternatives. The perspective of the Colombian Health System was adopted in a time scale consisting of the time of loss of consciousness until hospital admission. The probabilities of the events were obtained from a meta-analysis of clinical trials, and the information on costs from official sources and direct consultations with AED providers in Colombia. The costs were expressed in Colombian pesos of 2016, and the effectiveness in deaths prevented. Deterministic and probabilistic sensitivity analyses were performed to estimate the impact of uncertainty on the conclusions. Results: The cost-effectiveness of cardiopulmonary resuscitation with AED was COP $3,267,777 per death avoided. The probability that this intervention would be cost-effective is greater than 90% for cost-effectiveness threshold greater than 10 million Colombian pesos. Conclusion: A cardiopulmonary resuscitation program with early defibrillation using an AED in crowded public spaces is a cost-effective alternative for the Colombian Health System.

Path Analysis for Delirium on Patient Prognosis in Intensive Care Units

PURPOSE: This study was conducted to investigate relationship between delirium, risk factors on delirium, and patient prognosis based on Donabedian's structure-process-outcome model.METHODS: This study utilized a path analysis design. We extracted data from the electronic medical records containing delirium screening data. Each five hundred data in a delirium and a non-delirium group were randomly selected from electronic medical records of medical and surgical intensive care patients. Data were analyzed using SPSS 20 and AMOS 24.RESULTS: In the final model, admission via emergency department (B=.06, p=.019), age over 65 years (B=.11, p=.001), unconsciousness (B=.18, p=.001), dependent activities (B=.12, p=.001), abnormal vital signs (B=.12, p=.001), pressure ulcer risk (B=.12, p=.001), enteral nutrition (B=.12, p=.001), and use of restraint (B=.30, p=.001) directly affecting delirium accounted for 56.0% of delirium cases. Delirium had a direct effect on hospital mortality (B=.06, p=.038), hospital length of stay (B=5.06, p=.010), and discharge to another facility (not home) (B=.12, p=.001), also risk factors on delirium indirectly affected patient prognosis through delirium.CONCLUSION: The use of interventions to reduce delirium may improve patient prognosis. To improve the dependency activities and risk of pressure ulcers that directly affect delirium, early ambulation is encouraged, and treatment and nursing interventions to remove the ventilator and drainage tube quickly must be provided to minimize the application of restraint. Further, delirium can be prevented and patient prognosis improved through continuous intervention to stimulate cognitive awareness and monitoring of the onset of delirium. This study also discussed the effects of delirium intervention on the prognosis of patients with delirium and future research in this area.

Dexmedetomidine as a non-triggering anesthetic agent in a patient with MELAS syndrome and systemic sepsis: A case report

BACKGROUND: The selection of anesthetic agents is important in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome patient because serious and unexpected complications can occur after anesthetic exposure.CASE: A 30-year-old man with MELAS syndrome and sepsis underwent colectomy. Propofol was administered by step-wise until target effect-site concentration (Ce) 1.0 µg/ml and stopped for the loss of consciousness and to avoid hemodynamic instability. After the loss of consciousness, total intravenous anesthesia (TIVA) using dexmedetomidine (1.0 µg/ml/h) and remifentanil (1–4 ng/ml of Ce) was performed for the maintenance of anesthesia to avoid malignant hyperthermia and mitochondrial dysfunction. During the surgery, the bispectral index score stayed between 26 and 44, and increased to 97 after the end of anesthesia.CONCLUSIONS: TIVA with dexmedetomidine and remifentanil as non-triggering anesthetic agents in patients with MELAS syndrome and systemic sepsis may have advantages to decrease damages associated with mitochondrial stress and metabolic burden.

Lipid emulsion therapy of local anesthetic systemic toxicity due to dental anesthesia

Local anesthetic systemic toxicity (LAST) refers to the complication affecting the central nervous system (CNS) and cardiovascular system (CVS) due to the overdose of local anesthesia. Its reported prevalence is 0.27/1000, and the representative symptoms range from dizziness to unconsciousness in the CNS and from arrhythmias to cardiac arrest in the CVS. Predisposing factors of LAST include extremes of age, pregnancy, renal disease, cardiac disease, hepatic dysfunction, and drug-associated factors. To prevent the LAST, it is necessary to recognize the risk factors for each patient, choose a safe drug and dose of local anesthesia, use vasoconstrictor , confirm aspiration and use incremental injection techniques. According to the treatment guidelines for LAST, immediate application of lipid emulsion plays an important role. Although lipid emulsion is commonly used for parenteral nutrition, it has recently been widely used as a non-specific antidote for various types of drug toxicity, such as LAST treatment. According to the recently published guidelines, 20% lipid emulsion is to be intravenously injected at 1.5 mL/kg. After bolus injection, 15 mL/kg/h of lipid emulsion is to be continuously injected for LAST. However, caution must be observed for >1000 mL of injection, which is the maximum dose. We reviewed the incidence, mechanism, prevention, and treatment guidelines, and a serious complication of LAST occurring due to dental anesthesia. Furthermore, we introduced lipid emulsion that has recently been in the spotlight as the therapeutic strategy for LAST.

Distinct Topographical Patterns of Spike-Wave Discharge in Transgenic and Pharmacologically Induced Absence Seizure Models

Absence seizures (AS) are generalized non-convulsive seizures characterized by a brief loss of consciousness and spike-and-wave discharges (SWD) in an electroencephalogram (EEG). A number of animal models have been developed to explain the mechanisms of AS, and thalamo-cortical networks are considered to be involved. However, the cortical foci have not been well described in mouse models of AS. This study aims to use a high density EEG in pathophysiologically different AS models to compare the spatiotemporal patterns of SWDs. We used two AS models: a pharmacologically induced model (gamma-hydroxybutyric acid, GHB model) and a transgenic model (phospholipase beta4 knock-out, PLCβ4 model). The occurrences of SWDs were confirmed by thalamic recordings. The topographical analysis of SWDs showed that the onset and propagation patterns were markedly distinguishable between the two models. In the PLCβ4 model, the foci were located within the somatosensory cortex followed by propagation to the frontal cortex, whereas in the GHB model, a majority of SWDs was initiated in the prefrontal cortex followed by propagation to the posterior cortex. In addition, in the GHB model, foci were also observed in other cortical areas. This observation indicates that different cortical networks are involved in the generation of SWDs across the two models.

Motor Recovery after Seizure Induced by Repetitive Transcranial Magnetic Stimulation

Despite the low incidence, seizures induced by repetitive transcranial magnetic stimulation (rTMS) have been studied as they may cause neurological and functional regression. Seizures may predict poor outcomes in stroke patients, with no reports of improved neurological status after seizures. This is the first Korean report of a seizure induced by rTMS, and the first report in the literature of prompt motor recovery following a seizure induced by high-frequency rTMS of the primary motor cortex in a stroke patient. A 43-year-old man with left hemiplegia due to infarction in the right basal ganglia was enrolled 10 sessions of rTMS (each session consisted of 15 trains, with each train consisting of 5 seconds of stimulation at 20 Hz and 90% of resting motor threshold for each session followed by 55 seconds of rest). The self-limited seizure occurred within 5 seconds after the 10th session. It lasted for 60 seconds, with generalized tonic features in all four extremities and the trunk and loss of consciousness followed by prompt improvement in left hand muscle strength and coordination. Though the seizure is known to usually cause neurologic regression, this case showed neurologic improvement after rTMS even after the rTMS-induced seizure.